Adaptive assistive robotics: a framework for triadic collaboration between humans and robots

Robots and other assistive technologies have a huge potential to help society in domains ranging from factory work to healthcare. However, safe and effective control of robotic agents in these environments is complex, especially when it involves close interactions and multiple actors. We propose an effective framework for optimizing the behaviour of robots and complementary assistive technologies in systems comprising a mix of human and technological agents with numerous high-level goals. The framework uses a combination of detailed biomechanical modelling and weighted multi-objective optimization to allow for the fine tuning of robot behaviours depending on the specification of the task at hand. We illustrate our framework via two case studies across assisted living and rehabilitation scenarios, and conduct simulations and experiments of triadic collaboration in practice. Our results indicate a marked benefit to the triadic approach, showing the potential to improve outcome measures for human agents in robot-assisted tasks.

Determination of cannabinoids in human cerumen samples by use of UPLC-MS/MS as a potential biomarker for drug use

A quantitative analytical procedure was developed and validated by the use of Ultra- Performance Liquid Chromatography tandem Mass Spectrometry (UPLC-MS/MS) for the determination of Cannabidiol (CBD), Cannabinol (CBN), Δ⁹-Tetrahydrocannabinol (Δ⁹-THC), Cannabichromene (CBC), Cannabigerol (CBG) and 11-Nor- 9- Carboxy- Tetrahydrocannabinol (THC-COOH) in an unconventional biological matrix, cerumen. All the investigated calibration curves were characterized by high correlation values (R² ≥ 0.9965). The LODs and LOQs ranged from 0.004 to 0.009 μg g^-1 and 0.012-0.029 μg g^-1, respectively. Intra-assay and inter-assay precision were found to be 0.6-2.5%, and 0.8-2.2%, respectively. All recovery values of cannabinoids, with the use of the optimum cotton swab, at low (0.008 μg g^-1 of cerumen), medium (0.037 μg g^-1of cerumen) and high (0.16 μg g^-1 of cerumen) control levels, were estimated to be above 86%. The method developed here permitted the analysis of real cerumen samples obtained from fourteen cannabis users. In twelve out of fourteen cases, Δ⁹-THC was found to be positive, while in six cases, three major cannabinoids, CBN, CBG and Δ⁹-THC were quantified at concentrations 0.02-0.21 μg g^-1, 0.01-0.24 μg g^-1 and 0.01-4.86 μg g^-1, respectively. Subject #8 has the highest amount of the detected substances in both left and right ear, with Δ⁹-THC at a concentration of 1.85 and 4.86 μg g^-1, CBG 0.06 and 0.24 μg g^-1, CBN 0.10 and 0.21 μg g^-1, respectively. In addition, a detection window for the substances Δ⁹-Tetrahydrocannabinol, Cannabinol and Cannabigerol, in cerumen, was defined with success. In this case, Δ⁹-THC reached a maximum detection frame of up to fifteen days after smoking 0.5 g of marijuana cigarette. ANOVA-one-way analysis also indicated that the average earwax production of non-cannabis users differs significantly from the one of cannabis users (p = 0.048, <0.05). On the other hand, no significant difference was noticed between male and female users as the p value exceeded 0.05. In addition, no significant effect was observed on earwax production in regard to age, frequency and the last time of use (p > 0.05). These last three factors proved to have a significant impact on cannabinoids concentrations, since p values were less than 0.05.

P07.06.B The Impact of Using Intraoperative Ultrasound on Surgical Resection of High-Grade Glioma: A Systematic Review and Meta-Analysis

Background

Despite operative and adjuvant therapies, high-grade glioma (HGG) remains incurable, with the extent of surgical resection being one of the modalities that can improve patient survival. Enabling maximal safe and minimising post-operative neurological morbidity is a key aim of surgical resection. Numerous intraoperative surgical adjuncts are used at surgery and intraoperative ultrasound (IoUS), is one such adjunct. IoUS is a cost-effective, easy to use, repeatable surgical adjunct, safe for the patient and potentially available in all centres. Although it’s commonly used, no up to date systematic review exists collating and quantifying the level of evidence, delineating its impact on the extent of surgical resection.

Material and Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The study was registered with the PROSPERO database (CRD42022300034). Keywords across Medline/PubMed and Embase between 1996 and November 2021 were used. We included articles with adult supratentorial, histopathologically confirmed HGG patients aimed for resection, evaluating the correlation of IoUS use and gross-total resection (GTR). Meta-analyses were conducted according to the statistical heterogeneity between the studies using the Open Meta Analyst software.

Results

2942 articles were identified of which 16 were qualitative assessed and 10 used for quantitative meta-analysis. In qualitative assessment, a mean 4.63/8 Newcastle-Ottawa-Scale score was found for studies with no cohorts (no use of IoUS) and a mean score of 6/9, for studies including exposed versus non-exposed cohorts. The RCT was of moderate quality according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. A pooled analysis across 10 studies of HGG aimed for resection with the use of IoUS, led to GTR achieved in 168/365 cases, resulting in an overall GTR rate of 51.1% (95% CI, 33.9%-68.3%, p&lt;0.001), with great heterogeneity across studies (93.02% p&lt;0.001). In a subgroup meta-analysis of 3 studies of HGG aimed for complete resection only, GTR was achieved in 43/62 cases, yielding a 72.7% GTR rate (95% CI 41.6%-100%, p&lt;0.001) with significant heterogeneity across studies (I2 92.1%, p&lt;0.001). In 4 case-controlled studies, a total of 43.6% (48/110) GTR rate was achieved when IoUS was used versus 24.7% (65/263) when IoUS was not used, resulting in an odds ratio = 2.009 (95% CI 1.157-3.490, p &lt;0.001) for achieving GTR.

Conclusion

The meta-analysis showed a high GTR rate (72.7%) when HGG were aimed for complete resection and a two-fold probability of achieving GTR when IoUS is used than not used.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

P340 PARADOXICAL DIVERGENCE BETWEEN RATE OF SURVIVAL AND QUALITY INDICATOR OF CARE IN MYOCARDIAL INFARCTION ACCORDING TO PNE–AGENAS (ITALIAN NATIONAL HEALTHCARE OUTCOMES PROGRAM)

Background

The Italian National Healthcare Outcomes Program (PNE – AGENAS) each year provides quality performance measures for our Hospitals. Some measures refer directly to hard events such as mortality, others are focused over procedures that should be related to subsequent events, including mortality. The rate of PCI performed within 48 hours (48h–PCI) in patients with acute myocardial infarction (AMI) is currently used as a performance measures. An arbitrary standard of 35–40% of 48h–PCI for patients with AMI is considered the goal for a satisfactory practice.

Methods

We analyzed the PNE–AGENAS performance measures for the year 2020. Overall 1652 MI have been recorded in 2020 in Tuscany. We considered those Hospitals with &gt; 100 AMI. We related the 30 day and one–year mortality with the 48h–PCI of the 20 Hospitals identified. Of these latter 13 are Hospitals with a 24h PCI service.

Results

All the hospitals hosting a catheterization laboratory largely overcame the 48h–PCI quality standard although with a wide variation among sites (70,8 – 90.4%). On the contrary all the Hospitals without a cath–lab did not even approach the standard (0–33.%). The analysis of the mortality data both at 30 day and at 1 year showed a wide variability among Hospitals without an appreciable difference. The 30–day mortality rate ranged from 2 to 15% without any relationship with the 48h–PCI. In some cases better survival rates were recorded for those Hospitals with the worse 48h–PCI.

Conclusions

Several factors makes 48h–PCI a useless and even confounding measure of performance. As a matter of fact this measure does not consider the type of MI treated (STEMI vs NSTEMI), nor the presence or not of a cath lab. Also it does not take account for the case mix of the population of AMI treated. Patients with STEMI represents about 30% of the activity of an Hospital with a 24h cath –lab. It is obviously easy for such an Hospital to satisfy the proposed standard as these patients should receive their PCI well before 24 hours. The contemporary organizations do cooperate and are organized as networks. The 48h–PCI should be only used to evaluate these networks, not the single hospitals. In conclusion our analysis by showing the divergent and paradoxical phenomena of better or similar survival in spite of longer or similar 48hPCI highlights the need to abandon this useless and even confounding measure to evaluate the Cardiology practice in the Italian Hospital.

P32 SELF–LEARN IMPLEMENTATION OF ULTRASOUND FOR THE STUDY AND ULTRASOUND–GUIDED PUNCTURE OF VASCULAR ACCESSES IN THE IMPLANTATION OF PACEMAKERS AND IMPLANTABLE DEFIBRILLATORS

Background

The vascular access represents a crucial phase in the management of complications related to the implantation of devices. After the use of the axillary vein, which allows the elimination of intrathoracic complications as well as the subclavian crush of the catheters, the ultrasound–guided approach could represent the next step for the reduction of vascular complications.

Experience

All implants performed (n = 86) by an independent operator who implemented ultrasound to minimize complications related to central access were reviewed. During the first phase, the ultrasound–guided approach involved the study of vascular accesses before the start of the implant. The assessment took place before the preparation of the sterile field, for the localization of the axillary approach and for the study of the anatomical variants. It was immediately followed by the use of skin marks. The use of markers made it possible to attempt surgical isolation of the cephalic vein as a first approach. In case of failure, or the need for multiple accesses, the transition to central access could be facilitated by the presence of skin markers. This approach have not significantly modified the probability of successful axillary vein puncture without the use of venography (75% vs 71%, p NS). In the last phase all implants were performed with ultrasound–guided puncture with sterile technique before skin incision (n = 26). The procedures involved dual chamber (61%), single chamber (19%), CRTD (11%), dual chamber ICD. Ultrasound showed all cases of hypoplastic cephalic vein (15%). In the first three months of implementation, the success rate was 71.4% with 1 self–healing case of apical pneumothorax. In the following months the success rate rapidly increased to 94.1% (p &lt; 0.05) with no pneumo or hemothorax. The median time to effective puncture was 28 seconds (8–450sec) in the second phase. It was possible to isolate the cephalic vein in 40% of cases for two or three chamber implants.

Conclusions

The ultrasound study of the accesses performed before the incision allows to identify the anatomy and to define the course of the axillary vascular system and its relationships. When performed with a sterile approach, it allows direct ultrasound–guided puncture before the surgical incision, with a high success rate from the early stages of implementation.

Associations between serum biomarkers of cartilage metabolism and serum hyaluronic acid, with risk factors, pain categories, and disease severity in knee osteoarthritis: a pilot study

BACKGROUND

Specific serum biomarkers of cartilage metabolism such as cartilage oligomeric matrix protein (sCOMP) and procollagen type II C-terminal propeptide (sPIICP) as well as hyaluronan (sHA), a biomarker of synovitis, have been implicated in the pathophysiology of knee osteoarthritis (OA). However, the associations of these biomarkers with the severity of the disease and OA risk factors, including age and obesity remain inconclusive. This analysis examines the associations between these serum biomarkers and the radiographic severity of OA and knee pain, as wells as obesity, the age and gender of the participants, and other OA risk factors.

METHODS

From 44 patients with early knee OA and 130 patients with late knee OA we analyzed the radiographic severity of the disease using the Kellgren and Lawrence (KL) grading system. Moreover, 38 overweight healthy individuals were used as a control group. Specific information was collected from all participants during their recruitment. The levels of the three serum biomarkers were quantified using commercially available ELISA kits. Serum biomarkers were analyzed for associations with the average KL scores and pain in both knees, as well as with specific OA risk factors.

RESULTS

The levels of sCOMP were elevated in patients with severe late OA and knee pain and correlated weakly with OA severity. A weakly correlation of sHA levels and OA severity OA was observed. We demonstrated that only sPIICP levels were markedly decreased in patients with late knee OA suggesting the alterations of cartilage metabolism in this arthritic disease. Moreover, we found that sPIICP has the strongest correlation with obesity and the severity of OA, as well as with the knee pain at rest and during walking regardless of the severity of the disease. ROC analysis showed that the area under the ROC curve (AUC) was 0.980 (95% CI: 0.945-0.995; p < 0.0001), suggesting high diagnostic accuracy of sPIICP. Interestingly, gender and age had also an effect on the levels of sPIICP.

CONCLUSION

This study revealed the potential of serum PIICP to be used as a biomarker to monitor the progression of knee OA, however, further studies are warranted to elucidate its clinical implication.

Development of a Robotic Surgery Training System

Robotic Surgery is getting widely spread and applied to more and more clinical cases due to its advantages compared to open surgery, for both the patients and surgeons. However, Robotic Surgery requires a different set of skills and learning compared to open and also laparoscopic surgery. Tele-operation for a robotic system with hand controllers, the delay in the hand commands to be translated into robotic movements, slowness of the robotic movements, remote 2D or 3D vision of the actual operation, and lack of haptic feedback are some of the challenges that Robotic Surgery poses. Surgeons need to go through an intensive training for Robotic Surgery, and the learning and skill development continues throughout their early professional years. Despite the importance of training for Robotic Surgery, there are not yet dedicated, low-cost, and widespread training platforms; rather, surgeons mostly train with the same Robotic Surgery system they use in surgery; hence institutions need to invest on a separate surgical setup for training purposes. This is expensive for the institutions, it provides very limited access to the surgeons for training, and very limited, if any, access to researchers for experimentation. To address these, we have developed in our laboratory a low-cost, and experimental Robotic Surgery Trainer. This setup replicates the challenges that a Robotic Surgery system poses and further provides widespread access through internet connected control of the actual physical system. The overall system is composed of equipment that a standard engineering laboratory can afford. In this paper, we introduce the Robotic Surgery Training System and explain its development, parts, and functionality.

Cyprus' diatom diversity and the association of environmental and anthropogenic influences for ecological assessment of rivers using DNA metabarcoding

Human activities are the leading cause of environmental impairments. Appropriate biomonitoring of ecosystems is needed to assess these activities effectively. In freshwater ecosystems, periphytic and epilithic biofilms have diatom assemblages. These assemblages respond rapidly to environmental changes, making diatoms valuable bioindicators. For this reason, freshwater biomonitoring programs are currently using diatoms (e.g., Water Framework Directive). In the past ten years, DNA metabarcoding coupled with next-generation sequencing and bioinformatics represents a complementary approach for diatom biomonitoring. In this study, this approach is used for the first time in Cyprus by considering the association of environmental and anthropogenic pressures to diatom assemblages. Statistical analysis was then applied to identify the environmental (i.e., river types, geo-morphological) and anthropogenic (i.e., physicochemical, human land-use pressures) variables' role in the observed diatom diversity. Results indicate differences in diatom assemblages between intermittent and perennial rivers. Achnanthidium minutissimum was more abundant in intermittent rivers; whereas Amphora pediculus and Planothidium caputium in perennial ones. Additionally, we could demonstrate the correlation between nutrients (e.g., nitrogen, phosphorus), stations' local characteristics (e.g., elevation), and land use activities on the observed differences in diatom diversity. Finally, we conclude that multi-stressors and anthropogenic pressures together as multiple stressors have a significant statistical relationship to the observed diatom diversity and play a pivotal role in determining Cyprus' rivers' ecological status.

Diagnostic accuracy of Instantaneous Wave-Free Ratio (iFR) for the assessment of myocardial ischaemia: a comparison with non-invasive stress imaging

Background

Instantaneous Wave-Free Ratio (iFR) allows for the assessment of the haemodynamic effects of epicardial coronary stenoses without the need for hyperaemia; iFR is currently recommended as a means to evaluate myocardial ischaemia.

Purpose

To assess the diagnostic accuracy of iFR with respect to the identification of coronary epicardial stenoses causing ischemia. Therefore, we combined anatomical (% stenosis at invasive coronary angiography, ICA) and functional (non-invasive imaging stress test, NIST) information to obtain a “gold standard” for the identification of stenoses causing ischaemia.

Methods

We enrolled 71 patients (52 male, 19 female; age mean 68.4±8.1 years) with chronic coronary syndrome or low-risk acute coronary syndrome without ST segment elevation who had at least a NIST and who had at least one vessel with a 50%-85% stenosis at ICA. iFR was measured in all coronary arteries with stenosis &gt;50% and categorised according to the 0.89 threshold for ischaemia.

Results

iFR was assessed in 122 vessels. In a per-vessel analysis, in 56.7% ischaemia was present both at iFR and NIST, in 21.3% ischaemia was absent in both, while in 23.0% ischaemia was found at NIST but not confirmed by iFR. The overall accuracy of iFR with respect to NIST was 90.1%. However, when considering as the “gold standard” for coronary disease causing ischaemia the contemporary presence of an epicardial stenosis &gt;70% at ICA and a positive NIST, the diagnostic accuracy of iFR greatly improved. The sensibility, specificity, PPV, NPV and accuracy were 96.5%, 75.0%, 73.3%, 96.7% and 84.4%, respectively. In case of discordance between NIST and iFR, revascularization was based on iFR. At a mean follow-up of 23±18 months, the composite endpoint of MACE (major adverse cardiac events, defined as the composite of all-cause death, nonfatal MI and unplanned coronary revascularization) occurred in 16.4%, while death/MI occurred in 11.9%. Stratification according to the per-patient concordance between iFR and NIST showed no significant differences in rates of MACE (p=0.50) and death/MI (p=0.20). Stratification based on iFR showed a higher death/MI rate in iFR-positive patients (11.9% vs. 0%, p=0.047) and a trend to higher MACE rate (11.9% vs. 4.47% p=0.14),

Conclusions

The diagnostic accuracy of iFR is low when compared with NIST as the reference for myocardial ischaemia, but it is very high when compared with the combined presence of epicardial stenosis and positive NIST. Therefore, iFR can accurately guide the decision to treat or defer revascularization of intermediate coronary stenoses, being most useful in patients with multivessel CAD and when non-invasive functional data are lacking or discordant with anatomy.

Funding Acknowledgement

Type of funding source: None

Where to from here? A quality improvement project investigating burns treatment and rehabilitation practices in India

Objective

To describe the capacity of the Indian healthcare system in providing appropriate and effective burns treatment and rehabilitation services.

Results

Health professionals involved in burns treatment or rehabilitation at seven hospitals from four states in India were invited to participate in consultative meetings. Existing treatment and rehabilitation strategies, barriers and enablers to patient flow across the continuum of care and details on inpatient and outpatient rehabilitation were discussed during the meetings. Seventeen health professionals from various clinical backgrounds were involved in the consultation process. Key themes highlighted (a) a lack of awareness on burn first aid at the community level, (b) a lack of human resource to treat burn injuries in hospital settings, (c) a gap in burn care training for medical staff, (d) poor hospital infrastructure and (e) a variation in treatment practices and rehabilitation services available between hospitals. A number of opportunities exist to improve burns treatment and rehabilitation in India. Improvements would most effectively be achieved through promoting multidisciplinary care across a number of facilities and service providers. Further research is required to develop context-specific burn care models, determining how these can be integrated into the Indian healthcare system.

Whole-lesion histogram analysis metrics of the apparent diffusion coefficient as a marker of breast lesions characterization at 1.5 T

INTRODUCTION

To retrospectively assess the role of whole-lesion apparent diffusion coefficient (ADC) in the characterization of breast tumors by comparing different histogram metrics.

METHODS

49 patients with 53 breast lesions underwent magnetic resonance imaging (MRI). ADC histogram parameters, including the mean, mode, 10th/50th/90th percentile, skewness, kurtosis, and entropy ADCs, were derived for the whole-lesion volume in each patient. Mann-Whitney U-test, area under the receiver-operating characteristic curve (AUC) were used for statistical analysis.

RESULTS

The mean, mode and 10th/50th/90th percentile ADC values were significantly lower in malignant lesions compared with benign ones (all P < 0.0001), while skewness was significantly higher in malignant lesions P = 0.02. However, no significant difference was found between entropy and kurtosis values in malignant lesions compared with benign ones (P = 0.06 and P = 1.00, respectively). Univariate logistic regression showed that 10th and 50th percentile ADC yielded the highest AUC (0.985; 95% confidence interval [CI]: 0.902, 1.000 and 0.982; 95% confidence interval [CI]: 0.896, 1.000 respectively), whereas kurtosis value yielded the lowest AUC (0.500; 95% CI: 0.355, 0.645), indicating that 10th and 50th percentile ADC values may be more accurate for lesion discrimination.

CONCLUSION

Whole-lesion ADC histogram analysis could be a helpful index in the characterization and differentiation between benign and malignant breast lesions with the 10th and 50th percentile ADC be the most accurate discriminators.

Biomechanics of the human intervertebral disc: A review of testing techniques and results

Many experimental testing techniques have been adopted in order to provide an understanding of the biomechanics of the human intervertebral disc (IVD). The aim of this review article is to amalgamate results from these studies to provide readers with an overview of the studies conducted and their contribution to our current understanding of the biomechanics and function of the IVD. The overview is presented in a way that should prove useful to experimentalists and computational modellers. Mechanical properties of whole IVDs can be assessed conveniently by testing 'motion segments' comprising two vertebrae and the intervening IVD and ligaments. Neural arches should be removed if load-sharing between them and the disc is of no interest, and specimens containing more than two vertebrae are required to study 'adjacent level' effects. Mechanisms of injury (including endplate fracture and disc herniation) have been studied by applying complex loading at physiologically-relevant loading rates, whereas mechanical evaluations of surgical prostheses require slower application of standardised loading protocols. Results can be strongly influenced by the testing environment, preconditioning, loading rate, specimen age and degeneration, and spinal level. Component tissues of the disc (anulus fibrosus, nucleus pulposus, and cartilage endplates) have been studied to determine their material properties, but only the anulus has been thoroughly evaluated. Animal discs can be used as a model of human discs where uniform non-degenerate specimens are required, although differences in scale, age, and anatomy can lead to problems in interpretation.

Adherence to Mediterranean diet and 10-year incidence (2002-2012) of diabetes: correlations with inflammatory and oxidative stress biomarkers in the ATTICA cohort study

BACKGROUND

The purpose of this work was to investigate the links between oxidative stress, inflammation and coagulation and their effect on Mediterranean diet-diabetes relationship.

METHODS

In 2001-2002, a random sample of 1514 men (18-87 years old) and 1528 women (18-89 years old) was selected to participate in the ATTICA study, where Athens is the major metropolis. A validated questionnaire was used to assess lifestyle and dietary factors. Adherence to Mediterranean diet was recorded using MedDietScore. Among others, oxidative stress and inflammatory biomarkers were recorded. During 2011-2012, the 10-year follow-up was performed. Diabetes incidence was defined according to the American Diabetes Association criteria.

RESULTS

A total of 191 incident cases of diabetes were documented, yielding an incidence of 12.9% (13.4% in men and 12.4% in women). Medium and high adherence was found to decrease diabetes risk by 49% (95% CI: 0.30, 0.88) and 62% (95% CI: 0.16, 0.88), respectively, compared with low adherence. A logarithmic trend between Mediterranean diet and diabetes incidence was also revealed (p for trend = 0.042). Individuals with abnormal waist circumference (>94 for men, >80 for women) were benefited the most. Wholegrain cereals, fruits and legumes had the greatest predictive ability. The anti-diabetic effect of Mediterranean diet correlated with measurements of tumour necrosis factor-α, homocysteine and total antioxidant capacity.

CONCLUSIONS

The reported results support the role of Mediterranean diet as a promising dietary tool for the primary prevention of diabetes, by attenuating inflammation and fostering total antioxidant capacity. This dietary pattern may have therapeutic potential for many cardiometabolic disorders associated with inflammation and/or oxidative stress.

Exploring the path of Mediterranean diet on 10-year incidence of cardiovascular disease: the ATTICA study (2002-2012)

BACKGROUND AND AIMS

A Mediterranean diet has been associated with lower all-cause and cardiovascular disease (CVD) morbidity and mortality, but the clinical and behavioral pathway has not been well understood and appreciated. The aim of this work was to explore the path between adherence to a Mediterranean-type diet, lifestyle behaviors, clinical status, and a 10-year incidence of CVD.

METHODS AND RESULTS

The ATTICA study was carried out in the Athens area during 2001-2002 and included 3042 participants free of CVD at baseline (49.8% men, aged 18-89). Adherence to a Mediterranean diet was assessed using the MedDietScore (range 0-55). During 2011-2012, 2583 out of the 3042 participants were found during the 10-year follow-up (15% lost to follow-up). Adherence to a Mediterranean diet decreased CVD risk (relative Risk (RR) per 1/55 unit = 0.96, 95% confidence interval (CI): 0.93, 1.00), independently of various sociodemographic, lifestyle, and clinical factors. Subgroup analyses revealed that participants with an unhealthy lifestyle (i.e., smokers, and obese and sedentary persons) remained protected from CVD through a greater adherence to a Mediterranean diet (RR for smokers = 0.92, 95%CI: 0.88, 0.97; RR for obese participants = 0.90, 95%CI: 0.82, 0.979; and RR for sedentary participants = 0.95, 95%CI: 0.90, 0.99). Path analysis revealed that adherence to a Mediterranean diet not only decreases the levels of C-reactive protein and interleukin-6 but also has an independent protective role against CVD risk per se (total effect of the MedDietScore on CVD = -0.003, 95%CI: -0.005 to 0.000).

CONCLUSION

Adherence to a Mediterranean diet confers a considerable reduction on CVD risk, independent of various factors. Therefore, even subjects with unhealthy lifestyle behaviors may benefit from adherence to this diet, suggesting another dimension to prevention strategies.

Radiation doses in a newly founded Interventional Cardiology department

Coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) radiation doses were investigated in a recently founded Interventional Cardiology (IC) department. The study includes 336 procedures (177 CAs and 159 PTCAs) carried out with a Philips digital flat detector monoplane system. Patient dose was measured in terms of kerma-area product (KAP) and cumulative dose. Using appropriate conversion factors, peak skin dose (PSD) and effective dose (E) were estimated. Median values of KAP (Gy cm(2)), PSD (mGy) and E (mSv) were: 34 478 and 6.1, respectively for CA and 80 885 and 14.4 for PTCA, within European and international reference levels. Only 1.5 % of patients received radiation dose over the 2 Gy threshold (PTCA procedures) for deterministic effects and none reported any skin effect. Radiation doses were within international standards and comparable with other radiological examinations. The percentage of the high-risk patients for radiation skin effects is extremely low.

Evaluation of radiation dose during pacemaker implantations

The purpose was to evaluate patient radiation doses and compare with other interventional procedures. One hundred and twenty-eight procedures were carried out with a recently installed mobile undercouch C-arm machine with a 23-cm diameter image intensifier. The radiation dose is provided by the X-ray machine, in terms of cumulative dose (CD). Kerma-Area product (KAP) was then estimated from CD and the X-ray field size. Other patient parameters recorded were patient weight, age, kilovolt, milliampere and fluoroscopy time (T). Median (range) CD, KAP and T were 15.2 mGy (3.2-110 mGy), 6.3 Gy cm(2) (1.3-45.7 Gy cm(2)) and 5.2 (1.5-27.4 min) min, respectively. Median E was 1.1 mSv (conversion factor: 0.18 mSv per Gy cm(2)), which corresponds to approximately one lumbar spine X-ray radiography. The effective dose is much lower than a coronary angiography (8 mSv) or an electrophysiology study (6 mSv). Radiation dose is low compared with other interventional cardiology procedures.

First-trimester combined screening for trisomy 21 at 7-14 weeks' gestation

OBJECTIVE

To establish an algorithm for first-trimester combined screening for trisomy 21 with biochemical testing from 7 to 14 weeks' gestation and ultrasound testing at 11-13 weeks.

METHODS

This was a multicenter study of 886 pregnancies with trisomy 21 and 222 475 unaffected pregnancies with measurements of free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 7-14 weeks' gestation. Multiple regression modeling of log-transformed marker values was used to produce log multiples of the median (MoM) values for PAPP-A and free β-hCG. The models included terms for the center attended and the machine used for biochemical analysis, gestational age, maternal racial origin, maternal weight, smoking status and method of conception. Bivariate Gaussian distributions were fitted to log MoM PAPP-A and log MoM free β-hCG in trisomy 21 and in unaffected pregnancies. In each case the patient-specific risk for trisomy 21 was estimated by multiplying the individual maternal age-related risk with the likelihood ratio (LR) for fetal nuchal translucency (NT) according to the mixture model and the combined LR for maternal serum free β-hCG and PAPP-A. Estimates of detection rates for trisomy 21 and false-positive rates were calculated for combined screening with measurements of NT at 12 weeks together with measurements of free β-hCG and PAPP-A from 8 to 13 weeks.

RESULTS

In trisomy 21 pregnancies the mean log MoM free β-hCG increased linearly with gestation between 7 and 14 weeks, whereas the relation between log MoM PAPP-A and gestation was fitted by a quadratic equation such that the maximum separation between trisomy 21 and unaffected pregnancies occurs at 9-10 weeks. At a false-positive rate of 3% the detection rate of combined screening at 12 weeks was 86% and this increased to 90% by biochemical testing at 9 weeks and ultrasound scanning at 12 weeks. The detection rate increased to 92% by measuring PAPP-A at 9 weeks and free β-hCG at the time of the scan at 12 weeks.

CONCLUSION

The performance of first-trimester biochemical screening for trisomy 21 is best at 9-10 weeks rather than at 7-8 or 11-14 weeks.

Paclitaxel plus gallium nitrate and filgrastim in patients with refractory malignancies: a phase I trial

To determine the maximally tolerated dose of paclitaxel with and without filgrastim (G-CSF) when administered as a 24-hour intravenous infusion after a 120-hour infusion of gallium nitrate at a fixed dose of 300 mg/m2/24 hours, 40 patients were entered onto a trial lasting from September 1994 to September 1996. Eligibility included a diagnosis of an advanced malignancy not amenable to curative therapy and up to one previous chemotherapy regimen for metastatic disease. Gallium was administered at a fixed dose of 300 mg/m2/day as a continuous intravenous infusion for 120 hours. Paclitaxel starting at 90 mg/m2 was given concurrently with the last 24 hours of the gallium as a 24-hour intravenous infusion. Cycles were repeated every 21 days. Once the maximum tolerated dose (MTD) of paclitaxel was reached, G-CSF (5 microg/kg/day days 7-16) was added and paclitaxel dose escalation continued. The MTD for paclitaxel without G-CSF was 110 mg/m2 and 225 mg/m2 with G-CSF, with neutropenia being the dose-limiting toxicity. A partial response was noted in a patient who had thymoma and a complete response was achieved in a patient who had colon cancer. The recommended phase II dosage is gallium nitrate at 300 mg/m2/day over 120 hours, with paclitaxel at 110 mg/m2 over 24 hours without G-CSF or 225 mg/m2 over 24 hours with G-CSF and 0.5 mg calcitriol on days 1 through 7. Further trials of this modified regimen for outpatient administration are in progress.

The detection of alpha-fetoprotein in HBs Ag and HBe Ag carriers

We detected the alpha-fetoprotein (AFP) in 100 sera of HBsAg and HBeAg carriers, by radioimmunoassay (RIA). High values of AFP in 12 HBsAg carriers (mean value: 168,5 ng/ml) were found. Lower values were found in 3 HBeAg carriers (mean value: 22,5 ng/ml). We will study the prognostic and diagnostic value of this carcinoembryonic antigen in HBsAg and HBeAg carriers, and will consider the possible role of AFP in the development of primary hepatocellular carcinoma. We believe that the increased AFP levels seen during hepatic parenchymal regeneration may depress immunity in some cases, or alter immunosupervision in others, and this facilitates the development of neoplasia in liver.